Complications-of-Appendicitis. when things go wrong

complications of appendicitis
when things go wrong
presented by dr. suhaib almaghariz
general surgery specialist

1. Complications of Appendicitis

2. • Death is rare • Perforated appendix ~30% complication rate Peritonitis • Wound infection +/-dehiscence • Intra-abdominal abscess • F istulas • Small bowel obstruction (adhesions) (esp after perf) • Paralytic Ileus • Infertility Sepsis Complications

3. 3 Case : A 37-year-old woman with no past medical history went to ED complaining of vomiting and periumbilical abdominal pain for 6 hours. On physical examination, she was afebrile, BP 110/70, HR 85. Abdomen was soft, with no rebound or guarding. She was diagnosed with gastroenteritis, discharged with antiemetics, and told to return for persistent vomiting, pain, or new fever.

4. Case (cont.) : Patient went to OPD 2 days later with persistent abdominal pain; vomiting had resolved. On physical exam, patient was afebrile, with normal vital signs. Abdomen was diffusely tender, with localization around the umbilicus. Pelvic exam revealed no cervical motion and mild adnexal tenderness. Diagnosis: M ittelschmerz vs. ovarian cyst. Transvaginal ultrasound ordered for following week. Patient told to take NSAIDS for pain.

5. Case (cont .): The next day, the patient returned to the ED with persistent pain. She was seen by the same ED attending, who then asked a colleague to evaluate the case. This second ED attending performed a pelvic exam and ordered a CT scan of the abdomen and pelvis. CT revealed a perforated appendix.

6. Perforated Appendix

7. The major reason for appendiceal perforation is delay in diagnosis and treatment. In general, the longer the delay between diagnosis and surgery, the more likely is perforation. The risk of perforation 36 hours after the onset of symptoms is at least 15 %. Therefore, once appendicitis is diagnosed, surgery should be done without unnecessary delay. Perforated Appendicitis

8. Perforated Appendicitis Patients very ill; may require several hours of fluid resuscitation before induction of general anaesthesia Broad spectrum antibiotics directed against gut aerobes and anaerobes are initiated early in the evaluation and resuscitation phase A laparoscopic approach to perforated appendix appears to reduce incidence of post operative wound infection and ileus and shorter hospital stay

9. Diagnostic laparoscopy and assess whether or not to convert to an open appendectomy Any pus encountered is aspirated and sent for Gram stain and culture Oozing from inflamed retroperitoneum is easily controlled with argon beam coagulation(if available) Surgical excision of appendix as described Perforated Appendicitis… Management

10. P erforated appendicitis

11. Peritonitis It’s secondary type of peritonitis Life threatening if not treated quickly Patient presents with Immobile with shallow thoracic breathing Swelling and tenderness in the abdomen with pain ranging from dull aches to severe, sharp pain Fever and chills Loss of appetite Thirst Nausea and vomiting Limited urine output Inability to pass gas or stool

12. Case (cont.): Missed Appendicitis The patient was seen by general surgery and it was decided not to take her to the operating room immediately due to the peritonitis. She was admitted and started on IV antibiotics. Her hospital stay was prolonged due to ileus. On hospital day number #8, her WBC count began to rise. A repeat CT scan was obtained.

13. Intra-abdominal Abscess

14. Case (cont.): Missed Appendicitis CT revealed an intra-abdominal abscess “the size of an orange.” The patient underwent percutaneous drainage by interventional radiology. On hospital day #13, she was discharged home with a plan to follow-up for elective appendectomy.

15. Pelvic abscess Can occur irrespective of position of appendix Patient presents with spiking pyrexia several days following appendicitis Pelvic pressure symptoms like loose stools or tenesmus PR – Boggy mass in pelvis anterior to rectum Managed normally by or transrectal drainage under GA

16. Case (cont.): Missed Appendicitis Shortly after discharge, the abdominal pain returned. The patient returned to the ED and underwent a repeat CT scan, which revealed a small bowel obstruction. The patient went to the operating room the next day for lysis of adhesions and appendectomy. Eight days later, the patient was discharged home. She has returned to her previous state of health.

17. Small bowel obstruction Blockage occurs when the inflammation surrounding the appendix causes the intestinal muscle to stop working, and this prevents the intestinal contents from passing. If the intestine above the blockage begins to fill with liquid and gas , the abdomen distends and nausea and vomiting may occur.

18. Fistulas Typically for perforated appendicitis Fistulas to the skin generally close after any local infection is treated Fistulas to the bladder have been successfully diagnosed and treated laparoscopically in recent years

19. Infertility Many surgeons believe that girls and young women who suffer perforation of the appendix are at risk of developing subsequent tubal infertility This conviction presumably arose from the clinical observation that acute appendicitis complicated by perforation sometimes caused severe intra abdominal infection The resulting peritoneal adhesions were thought to obstruct the fallopian tubes, leading to tubal infertility Several previous studies have found an association between complicated appendicitis and female infertility (1–4), whereas others have not detected a relation

20. Sepsis A feared complication of appendicitis is sepsis, a condition in which infecting bacteria enter the blood and travel to other parts of the body. This is a very serious, even life-threatening complication. Fortunately, it occurs infrequently.

21. Chronic or Recurrent Appendicitis A small number of patients report episodic bouts of RLA pain in absence of acute febrile illness Some are found to have appendicoliths on CT or sonographic evidence of an enlarged appendiceal diameter Most will have both surgical and pathologic evidence of chronic inflammation(fibrosis) Dilemma is more difficult when report of pain is not accompanied by other clinical or radiographic findings

22. Appendicitis in pregnancy Complications: More chances of perforations and peritonitis Incidence: 4 -19% - non pregnant patients 57% - pregnant women ( Tracey & Fletcher,2000) Abortion , Fetal loss ~ 15% (1st trimester) Decreased birth weight Other surgical complication – wound infection , atelectasis No congenital malformation No stillborn infants

23. Perforation – why more ??? Position change of appendix No containment of infection by omentum Inability of omentum to isolate infection More generalized peritonitis

24. Complications of Appendicectomy

25. Pre-operative Intra-operative Post-operative

26. Pre-operative complications Risks for any anesthesia include the following: Problems with breathing Chest infection Reactions to medications

27. Intra-operative complications If gridiron incision used then ligation of arterial twig from Supf circum iliac artery should be done to prevent excessive blood loss Sparing of iliohypogastric nerve Normal-appearing appendix What to do? Consensus is still lacking even after introduction of laparoscopy Recent practice is to remove the appendix and perform a thorough search for other causes of patients’ symptoms Check Small Intestine, Mesentery and Pelvis

28. Absent appendix Caecum should be mobilised and taenia coli mobilised till confluence with caecum before diagnosis of ‘absent appendix’ is made Appendicular tumour Small size( <2cm in diameter) appendicectomy Larger size Right Hemicolectomy Internal injuries

29. Post-operative complications Relatively uncommon Mainly reflect degree of peritonitis Wound infection Most common; occurs in 5-10% patients Higher in those with perforation ; about 25% Present as pain and erythemia of wound on 4 th to 5 th day post-op Treated by wound drainage and antibiotics Most common organism Bacteriodes species and Anaerobic streptococci

30. Intra-abdominal abscess Rare because of pre-op antibiotics Spiking fever, malaise and anorexia developing 5-7days post-op Sites Interloop , Paracolic , Pelvic and Subphrenic Use Abdominal USG and CT Drainage done mostly percutaneously Laparotomy only to those where site cannot be identified by imaging Ileus may last for some days especially after removal of gangrenous appendix If lasts for more than 4-5days with accompanying fever, one should suspect intra-abdominal sepsis

31. Small bowel obstruction Occurs in less than 1% of patients operated for uncomplicated appendicitis and in 3% cases with perforation About half present within first year Respiratory problems Rare complication Postoperative abdominal surgery patients require analgesics to facilitate deep breathing, which minimizes the risk of atelectasis Some also advocate physiotherapy in severe cases

32. Stump Appendicitis Residual tissue left after an initial appendectomy risks the development of stump appendicitis Typically, patients present with signs and symptoms similar to acute appendicitis; however, due to prior surgery, the diagnosis is difficult and the rate of appendiceal stump perforation is extremely high Portal pyaemia ( Pylephlebitis ) Rare but serious complication of gangrenous appendicitis Associated with high fever, jaundice and rigors Due to septicemia in portal system Development of intrahepatic abscesses Treated by systemic antibiotics and percutaneous drainage

33. Venous Thrombosis Rare Seen mainly in elderly and women on OCPs Therefore there’s need for prophylaxis Faecal fistulae Occasionally seen following appendicectomy in Crohn’s disease Right inguinal Hernia Seen when Gridiron incision done and injury to iliohypogastric nerve

34. Thank you